If you have a co-occurring disorder (a substance use
disorder and a mental health disorder) this article will help you understand what
types of integrated treatment you need.

OK – the experts recommend integrated treatment for
co-occurring disorders, but what does this look like in reality? Where are you supposed to get treated and how are you supposed to pick and choose among all your options... how is this supposed to work?!?

In severe cases, is it a psychiatric hospital you need or a
residential addiction treatment program which specializes in care for those
with co-occurring disorders?

In milder cases, do you need outpatient addiction treatment with supplementary medication or general counseling combined with AA/NA or SMART Recovery in the evenings?

Getting appropriately matched integrated treatment greatly improves
your odds of success, but how are you supposed to know what you
need when faced with such an overwhelming array of options?

Well, for starters, this isn’t a decision you should make
alone. You probably don’t know about all local programs and treatment options
and you probably shouldn't build your recovery on the unstable grounds of
self diagnosis. Find a professional you trust and get help
designing a treatment program that makes sense – and if you can, get a loved-one
involved in the discussion too.

But though you shouldn’t make this decision without help,
getting educated always makes sense. At minimum it allows for an informed
conversation with your healthcare team and at best it saves you from wasting
your time on a treatment plan that won't work.

Read on to learn more about:

A system called the 4 Quadrant Model that provides a basic
framework for matching disorder severity with appropriate treatment.

Treatment options for each of the 4 quadrants (for whichever
of the 4 squares you fit into).

Assessment instruments you can use to assess the severity of
your mental disorder and your substance use disorder.

An introduction to addiction
treatment programs designed for
co-occurring disorder clients.

The 4 Quadrant Model – an Intro

Professionals use the 4 quadrant model as a diagnostic tool
to help determine correct treatment recommendations.

As the name would indicate, the tool is based on a 4 box model, and every person with a co-occurring disorder
will fall into one of the 4 quadrants.

Once you identify your quadrant you can narrow your focus onto treatment options that make the most sense for you.

In some cases, people
in this quadrant might benefit from some integration of services between mental
health and addiction treatment providers.

Quadrant 2

People with serious mental illness and milder
substance use disorders are best served within the metal health system.

You can access the mental health system through outpatient mental health centers
(such as clinics) or more intensive residential or inpatient programs. Many
mental health providers will also offer some addiction treatment,
such as motivational interviewing or skills training. To find mental health
services in your area, visit SAMHSA’s Behavioral Health Locator Tool.

Quadrant 3

People with more serious substance use disorders and less
serious mental health disorders should receive substance abuse treatment as the
primary focus of care.

The types of treatment facilities capable of providing
care for people in this quadrant are often referred to as dual diagnosis
capable (DDC) or dual diagnosis enhanced (DDE). See below for more information
on these types of specialty programs.

Evaluate Yourself

So what to do when facing substance use and mental
disorders of unknown severities?

Well, again – since you can’t correctly match treatment
without an accurate severity diagnosis for each condition, you should get a
professional involved in the process. (Although you might wonder how you’d do
this, any quality treatment program should insist on a comprehensive assessment
before admittance, to ensure an accurate program fit.)

But for your own education, here are a couple of assessment
instruments that may provide you with a better understanding of the seriousness
of your 2 conditions.

Once you’ve diagnosed the severity of each independent condition
you’ll know which quadrant you fall into – and thus what type of care you likely
need.

The Global Assessment of Functioning
Scale

One tool that a professional might use to determine the
seriousness of your mental illness – and which you can use on yourself or a loved one, to get a basic idea of your situation – is called theGlobal Assessment of Functioning Scale.3

This scale is intended for adults over the age of 18. It
provides you with a score from 0 to 100 that corresponds with the severity of
your mental health disorder – the lower the score, the greater the disorder
severity.

As a general guide – scores greater than 50 correspond with
less severe mental illness (quadrants 1 and 3) and scores of 50 or less correspond
with more serious mental illness (quadrants 2 and 4).4

100 - 91 - You have excellent functioning across a range of
everyday activities and no symptoms of any mental disorder. Other people
interact with you by choice because of your positive personality. You never
allow common problems to grow out of hand.

90 - 81 – You have no or very few symptoms of any mental disorder
and a good level of functioning across a range of everyday activities. You have
normal everyday problems but are generally satisfied with life and socially
effective.

80 - 71 – You have some symptoms of mental disorder, but these
symptoms are impermanent and they occur as a normal response to an
environmental or behavioral stressor. Your symptoms cause you very little
impairment in your general functioning at work/school and in relationships. An
example could be feeling low for a few days after failing an important exam.

70 - 61 – You have lasting mild symptoms of a mental disorder
but you still function well at school/work and you’re able to maintain
relationships.

60 - 51 – You have moderate symptoms of a mental disorder or
you have moderate difficulties with normal everyday activities and social
functioning (for example, you have occasional panic attacks, some trouble
keeping friends or you’re frequently in trouble at work or school.)

50 - 41 – You have serious symptoms of a mental disorder (for
example, major depression, suicidal ideation, etc.) or you have serious
problems with everyday social functioning (can’t get or keep a job, no social
contacts).

40 - 31 – You have serious symptoms and at least some loss of
contact with reality or you have major impairment in many areas of normal
social functioning (for example, because of your mood disorder you don’t leave
the house and you neglect all responsibilities and self care.)

30 - 21 – You have a serious loss of contact with reality
which influences your behaviors, or you have serious inability to maintain
normal communication or behaviors (very inappropriate acts, for example) or you
have a complete inability to function in basically all areas.

20 - 11 – You are in moderate danger of hurting yourself or
others or you sometimes don’t maintain even minimal standards of personal hygiene
(use of toilet, for example) or you can no longer communicate at all.

10 - 1 – You are in serious and lasting danger of hurting
yourself or others. You never maintain minimum standards of personal hygiene or
you make serious suicide attempts.

Note – this scale is intended to serve as one diagnostic
tool to be used in conjunction with other contextual behavioral and environmental information - and in combination with subjective common sense.

Evaluate Your Substance Use Disorder Severity

As a very general guideline:

People with low to moderate substance use
disorders (abuse - not addiction, little compulsion, etc.) would qualify for less intense substance disorder treatment as in quadrants 1 and 2.

People with substance use disorders defined by addiction,
compulsive use and loss of control would qualify for more intense addiction treatment, as in quadrants 3 and 4.

When making treatment recommendations, professionals
generally use the American Society of Addiction Medicine’s (ASAM) Placement Criteria. By considering your situation against the following 6 placement
criteria you may gain a sense of whether you need high or low intensity
substance use disorder treatment.5

1. Acute Intoxication
and Withdrawal

A person needing medical management of withdrawal or
intoxication requires more intensive substance abuse treatment than a person
already detoxed and clean/sober.

2. Biomedical
Conditions and Complications

You require more intensive treatment if you have acute or chronic physical
health conditions that complicate participation. For example,
someone weakened after a pancreatitis attack or with poor liver function might
require more intensive treatment (residential) than someone in good physical shape (able to travel to outpatient meetings).

3. Emotional, Behavioral or Cognitive Complications

In addition to co-occurring mental health disorders, people
with diminished cognitive capacities may require more intensive treatment
(cognitive deficits may be a transient side effect of withdrawal or
abuse.)

4. Readiness to Change

A person very motivated to change may do well in a less
intensive treatment environment, while a person with greater ambivalence about
change may require greater structure and intensity to achieve the same outcome.

5. Relapse or Continued Use

If you can’t maintain even short periods of abstinence and
acute intoxication interferes with your ability to participate in outpatient
treatment, then you likely require residential treatment.

6. Recovery Environment

People lacking a safe and sober living environment typically
require more intense treatment than people in supportive environments.

Quadrant 3 Care - DDC and DDE Programs

Programs designed for people needing co-occurring disorder services are called dual diagnosis capable
(DDC) and dual diagnosis enhanced (DDE) programs.1

DDC Programs – These programs are set up to address the
interaction between mental disorders and substance use disorders, even when
focused primarily on addiction treatment. DDC programs offer treatment content
that is adapted to the unique motivation, relapse prevention, recovery planning
and treatment integration needs of clients with co-occurring disorders.

DDE Programs – Compared to DDC programs, DDE programs offer
a higher level of treatment integration and can accept people for primary
addiction treatment who have more serious mental health disorder symptoms or
functional impairment.

To find DDC and DDE programs, you can use SAMHSA's Substance
Abuse Treatment Locator Tool, which allows you to search for programs in a
radius around your home. When using the tool, navigate to the advanced search and
narrow the field by selecting programs that offer ‘a
mix of substance abuse and mental health treatment services'.

Challenges and Special Considerations

Use the quadrant framework with a healthy-dose of common sense – especially when considering how
fluid and changeable symptoms can be, even even short periods of time.

You don’t stay as you are and if you did, treatment wouldn’t
be much worth getting. As your mental health symptoms improve or your substance
abuse declines, you will need reassessment to ensure that your treatment
continues to match your needs.6

In some cases, such as when dealing with substance-induced
psychosis, suicide attempts or medication noncompliance, a person that’s
initially classified in quadrant 4 could stabilize within hours or days and
then no longer benefit from quadrant 4 treatment recommendations.4